PERIODICUM BIOLOGORUM
VOL. 115, No 2, 145–148, 2013
Reducing the incidence of adverse events
in anesthesia practice
MATIJA BELAVI]1
MIRJANA LON^ARI]-KATU[IN1
JOSIP @UNI]1,2
1
Department of Anesthesiology,
Intensive Medicine and Pain Medicine,
Karlovac General Hospital,
Karlovac, Croatia
2
Karlovac University of Applied Sciences,
Karlovac, Croatia
Correspondence:
Matija Belavi}
Karlovac General Hospital,
Andrije [tampara 3, 47 000 Karlovac, Croatia
E-mail address: mbelavic1@gmail.com
Key words: complication, accreditation,
registries, nerve blockade
Received May 29, 2013.
UDC 57:61
CODEN PDBIAD
ISSN 0031-5362
Critical overview
Abstract
Background and purpose: adverse event during anesthesia is defined as
an event that may result in the development of complications and is caused
by human error, failure of the apparatus, the selected anesthetic techniques
and individual reaction of the patient. Timely detection of adverse events
prevents complications and their analysis through the register of the same to
the adoption of preventive and remedial measures.
Materials and methods:The Department of Anesthesiology in General
Hospital Karlovac, in accordance with the accreditation standards of the
Republic of Croatia monitors adverse events during anesthesia, the waking
up period and the stay on the ward during the first 24 hours, and the type of
anesthesia techniques applied.
Results: During the 2012, a total of 4244 anesthesia with a 1.25%
complications was done. We have been monitoring the number of anesthesia
since 2011. when the percentage of complications was 5.4%. This is the basis
to conclude that there is a tendency to reduce the number of complications.
Anesthesia was classified as general and regional. The use of ultrasound
contributes to safety of regional anesthesia, especially nerve conduction
anesthesia of extremities and thus reducing the volume of local anesthetic
administered and its toxicity. The incidence of complications of regional
anesthesia among all regional anesthesias done during the 2012 was 0,31%.
Conclusion: Keeping the register of complications during anesthesia has
led to increased awareness of the need to record them and analyze the causes
and consequences of complications at the department meetings. There is a
trend of increased use of regional anesthesia techniques as indicated.
INTRODUCTION
A dverse event during anesthesia is defined as an event that may
result in the emergence of complications, and occurs due to human
error, failure of the apparatus, the selected anesthetic techniques and
the individual reaction of the patient (1). Weaknesses and shortcomings
of the anesthetic procedures and the work of anesthesiologists are
monitored by recording and analyzing the occurrence of adverse events
and the consequent complications of anesthesia. By timely detection of
unwanted events, we have tried to prevent the occurrence of com-
plications, and increase the safety of anesthesia procedures. As a part of
quality assurance and accreditation in our institution, we followed the
number of anesthesia, the type of anesthesia techniques and com-
plications of anesthesia during one-year period.
M. Belavi} et al.. Adverse events and complications of anesthesia

MATERIALS AND METHODS TABLE 1

Anesthesia type division in 2012.
We noted the complications of anesthesia, the type of
anesthesia during which the complications occurred, and
the time of the unwanted occurrence in the hospital Type of anesthesia Number % of total
’Quality’ programme. That meant: an introduction to General 3438 81%
anesthesia, maintenance of anesthesia or awakening from Central block 663 15,62%
anesthesia, and the first 24 hours postoperatively (room
awakening, department or ICU). The total number of Regional anesthesia 143 3,37%
anesthesia and type of administered anesthetic techni-
ques in one-year interval was noted as well. We divided
the type of anesthesia techniques on general anesthesia TABLE 2
and regional anesthesia techniques (Fig. 1). Per operative complications.

Type of anesthesia Number of % of total

100 complications number
General 40 0,94%
80 Central block 11 0,26%
Regional anesthesia 2 0,05%
60

40
TABLE 3
20 Type of complication: central block, regional anesthesia.

Type of block Number of % of total

0 complications number of
Types of Peripheral block: 3,4% blocks
anesthesia Spinal 8 0,99%
Spinal and epidural: 15,6%
General: 81% Epidural 3 0,37%

Figure 1. The division of anesthesia according to its type.

Deep cervical block – –
Axillar block – –
Supraclavicular block 1 0,12%
Regional techniques were divided on central blocks
(spinal and epidural) and peripheral blocks of nerves. Femoral block 1 0,12%
The number of complications for each type of anesthesia Popliteal block 1 0,12%
was expressed as a percentage of the total number of
incurred anesthesia (Table 2), and complications of re-
gional and their percentage in the total number of re-
gional anesthesia (Table 3). Anesthesia without
100
complications – 98,75%
Every specific complication according to the type of
regional anesthesia was described and compared to com- 80 With complications – 1,25%
plications described in foreign literature.
60

RESULTS
40
During 2012, a total number of 4244 anesthesias were
done at Karlovac General Hospital. This number in- 20
cludes 3438 general anesthesia, 663 central blocks and
143 peripheral blocks (Table 1). A total of 53 compli-
0
cations were recorded, i.e. 1.25% out of total anesthesia
(Fig. 2). The percentage of complication rate according Figure 2.
Complication rate compared to the total number of per-
to the type of anesthesia compared to the total number of formed anesthesia 2012.
incurred anesthesia makes 0.94% in general, 0.26% in the
central blocks and 0.05% for peripheral blocks (table 2).
The number of complications of regional anesthesia two complications of peripheral blocks (Fig. 3). The
compared to the total number of 806 regional anesthesia types of complications depending on the type of regional
in 2012 was 11 complications in the central blocks and anesthesia were as following:

146 Period biol, Vol 115, No 2, 2013.

Adverse events and complications of anesthesia
Number of regional anesthesia without complications – 793
Spinal anesthesia with compl. – 8
Epidural anesthesia with compl. – 3
Peripheral blocks with compl. – 2
Figure 3. The number of complications by type of regional anesthesia
in relation to the total number of regional anesthesia.
a) with spinal anesthesia – an anaphylactic reaction to
antibiotic, inadequate block meaning inadequate anal-
gesia in two cases, the occurrence of paresthesia para
gluteal right 6 hours after the spinal anesthesia, post
puncture headache, the insufficient amount of spinal
block, redness of the skin and flushed face after syn-
tocinon injection, bradyarrhythmia slower than 30/min.
which recovers after the administration of ephedrine. b)
in epidural anesthesia – the inability to set the catheter,
the occurrence of motor weakness of one foot which
recovers after removing the continuous infusion of local
anesthetic and the emergence of hypotension after a
bolus of local anesthetic in anesthesia concentration for a
Caesarean section
c) in peripheral regional blocks we had inadequate
analgesia in supraclavicular block and prolonged lack of
motor skills and sensibility for more than 24 hours at
femoropopliteal block followed by the complete recovery
DISCUSSION
Timely detection of adverse events prevents compli-
cations and their analysis using the register enables the
adoption of preventive and remedial measures, empha-
sizing patient safety and improving the work quality of
anesthesiologists. Collecting data on anesthetic compli-
cations in different hospitals throughout the country
creates the possibility of drawing a national database.
Anesthetic complications database makes information
more available to other anesthesiologists who can on
time recognize and avoid the repetition of such com-
plications. Anesthetic complications database also creat-
es the possibility of education for young anesthesiologists
as well as data comparison between countries thus creating
access to information from other countries and creating
international database. In this way, the level of quality
and safety of anesthesia is raised, and the same model has
been applied in aviation, nuclear power plants and oil-
Period biol, Vol 115, No 2, 2013.
M. Belavi} et al..
rigs. According to the accreditation standards in the Re-
public of Croatia, the Regulations on the accreditation
standards for hospital health institutions (Official anno-
uncement publications 31/11) and the Regulations on
the quality standards of health care and the way they
application (Official announcement publications 79/11)
and all within the system to ensure and improve the
quality of health care (SOPK), following the protocol of
application of all forms of anesthesia PSOPK. 7-06, our
Department of Anesthesiology, Intensive Medicine and
Pain Treatment in Karlovac General Hospital monitors
adverse events, i.e. complications during anesthesia, the
waking up period and the stay on the ward in the first 24
hours, as well as the number and type of anesthetic
techniques during the six-month period. The Depart-
ment has to perform an internal review every 6 months,
then make a report for the six-month period. Each six-
-month period report has to be submitted for the Admi-
nistration Management review. The individual register
of anesthetic complications depends on the anesthesio-
logists themselves. The lack of complication reports is
due to fear or guilt and condemnation of others col-
leagues or a sense of their own infallibility and lack of
recognition for their mistakes¹. Hospital policies which
exclude the feeling of quilt, check-lists with adverse
events filled in by the physicians and technicians, mutual
encouragement from the superior physicians and the
discussion about the reported complications at profes-
sional meetings of the Department which have the goal
to improve the anesthesia techniques and prevent the
repetition of such mistakes all contribute to the report of
complications. Anesthesia complications are followed
through the organ systems and may include cardiovas-
cular (hypotension, arrhythmia, cardiac arrest), respira-
tory (bronchospasm, laryngospasm, aspiration pneumo-
nitis, acute respiratory failure), thromboembolic incidents,
bleeding (if it is larger and requires compensation of
blood products), renal (acute renal failure with oliguria
or anuria), acute liver failure, metabolic (hypoglycemia,
thyrotoxicosis, neurological (central event or nerve palsy
due to a bad position on the table or after peripheral
blocks), complications of regional anesthesia, technical
Percentage of complications
6
5
4
3
2
1
0
2011. 2012.
Figure 4. The display of anesthesia complications decrease trend.
147
M. Belavi} et al..
complications (human factor, failure of the apparatus or
equipment in the surgery). The number of anesthesia,
type of anesthetic techniques and anesthetic compli-
cations have been followed since 2011. The incidence
rate of complications in 2011 was 5.4% and in 2012 it
decreased to 1.25%. There is therefore a reduction ten-
dency of the total number of complications in anesthesia
as well as regional anesthesia complications (Fig. 4). Some
of anesthetic complications are rare in practice, but can
be life threatening (anaphylactic reaction, high spinal
block, spinal or epidural hematoma, intravascular inje-
ction of local anesthetic with an arrhythmia, cardiac
arrest or convulsions). The most common complications
of spinal anesthesia are hypotension and post puncture
headache (2). Anaphylactic reaction after cefazolin pro-
phylaxis and bradyarrhythmia slower than 30/min which
recovered after the use of ephedrine were life threatening
complications we encountered during spinal anesthesia.
Hypotension occurred with epidural anesthesia after
anesthetic concentration of levobupivacaine, accompa-
nied by motor weakness of the extremities after conti-
nuous infusion of local anesthetic, which recovered by
discontinuing the usage of analgesia. Rare complications
such as neurological disturbances due to occurrence of
epidural hematoma³ with the need of urgent surgery
were not recorded. However, it should be noted that such
patients, especially parturient women postpartum after
removing peridural catheter, should be monitored after-
wards in order to exclude unwanted neurological signs.
The safety of regional anesthesia and nerve conduc-
tion anesthesia in extremities is increased by the appli-
cation of the ultrasound, thereby reducing the volume of
local anesthetic administered and its toxicity. In our pap-
ers, we had one case of a prolonged outage of sensibility
and motor skills after the femoropoliteal block, which
lasted more than 24 hours. Spontaneous recovery of neu-
rological functions occurred on the second postoperative
148
Adverse events and complications of anesthesia
day. The incidence of our complications related to peri-
pheral blocks is not higher than the incidence of the ones
published in foreign literature (4). The study by German
authors shows that permanent neurological damage after
peripheral block is rare (5). High injection pressures at
the onset of injection may indicate an intraneural needle
placement and lead to severe fascicular injury and per-
sistent neurological deficits. If these results are applicable
to clinical practice, avoiding excessive injection pressure
during nerve block administration may help to reduce
the risk of neurological injury (6).
CONCLUSION
Keeping the register of complications during anes-
thesia has led to increased awareness of need to record
them by the anesthesiologists and to analyze the causes
and consequences at the department meetings. A trend
of increased use of regional anesthesia techniques as
indicated has been noticed as well as the decreasing trend
of anesthetic complications.
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Period biol, Vol 115, No 2, 2013.